EM E1: Renal/GU

What is the MC type of renal trauma?

*usually assoc w/ other organ injury

blunt (nonpenetrating)

What is usually the sign of renal trauma?

gross hematuria (but can be microscopic)

What should you order to workup renal trauma?

CBC, CMP, UA, CT A&P w/ renal US

What is the tx for renal contusion or mild laceration?

conservative, +/- ureteral stent, hydration & analgesic, f/u with nephro

What is the tx for severe renal laceration or injury to renal artery/vein?

emergent surgery

What is an AKI?

deterioration of renal function over hours/days resulting in the accumulation of toxic wastes and the loss of internal homeostasis

What complicates the dx of AKI?

acute declines in GFR are often asx (especially early in the course)

What is the MCC of intrinsic renal failure?

Ischemic renal injury

What are sx of a prerenal AKI?

hypovolemia, thirst, dec urine output, dizziness, orthostatic hypotension

What should be suspected in any pt presenting after a period of hypotension secondary to cardiac arrest, hemorrhage, sepsis, drug overdose, or surgery?

Acute tubular necrosis (ATN)

What are sx of glomerular intrinsic renal failure?

nephritic syndrome of hematuria, edema, and HTN

What are sx of allergic intrinsic renal failure?

fevers, rash, arthralgias, exposure to certain meds including NSAIDs and Abxs

How does postrenal failure typically present?

older men with prostatic obstruction and sxs of urgency, frequency, and hesitancy; OR flank pain & hematuria

What are possible causes of anuria?

(UO < 100 ml/d)

urinary tract obstruction, renal artery obstruction, rapidly progressive glomerulonephritis, bilateral diffuse renal cortical necrosis

What are possible causes of oliguria/hypouresis?

(UO 100-400 ml/d)

prerenal failure, hepatorenal syndrome (severe liver failure resulting in decreased renal perfusion)

What are possible causes of nonoliguria?

(UO > 400 ml/d)

acute interstitial nephritis, acute glomerulonephritis, partial obstructive nephropathy, nephrotoxic & ischemic ATN, radiocontrast-induced ARF, rhabdomyolysis

What lab value provides an accurate & consistent estimation of GFR?

Serum creatinine

What lab value is emerging as a superior biomarker for early kidney injury bc it is able to identify kidney injury while Cr levels remain in the normal range?

Cystatin C

What lab findings are common in AKI?

hyperkalemia, hypocalcemia

What is the test of choice for urologic imaging for AKI?

Renal US

What size of kidneys suggests CKI?

< 9 cm

*also marked hypocalcemia

What should you focus AKI tx on?

*after providing adequate airway/ventilation if needed

fluid management -often sufficient to tx many forms, but monitor for life-threatening fluid overload

(begin before dx is firmly established)

What potentiates & exacerbates all forms of AKI?

Hypovolemia

What is a renal vascular vasodilator that is ideal for HTN emergencies affecting the kidneys?

Fenoldopam

What is a potent vasodilator that increases renal blood flow in ARF?

low-dose Dopamine

What is the MCC of UTI?

E. coli

What does flank pain/CVA tenderness indicate?

referred pain of cystitis; if fever/chills present = acute pyelonephritis

Does a negative UA excludes UTIs?

nope -ALWAYS culture for definitive dx

What patients should you order a urine culture for?

*get midstream void

- Suspected acute pyelonephritis

- RFs for subclinical pyelonephritis

- Need to be hospitalized

- Chronic indwelling catheter

- Pregnant women, children, adult males

What is the tx of UTI in pregnancy?

Nitrofurantoin or Cephalosporin

What is the tx for UTIs?

*culture to ensure abx will work

Bactrim, Ciprofloxacin, Nitrofurantoin

What is the tx for a UTI if the pt has intense dysuria?

Pyridium or Urispas

What are reasons to admit acute pyelonephritis?

- Can't tolerate PO

- Unstable vital signs

- Severe S&S

- Pregnancy

- Comorbid disease

What is the outpt tx for acute pyelonephritis?

Ceftriaxone or gentamicin or tobramycin (day 1) + FQ (day 2-14)

What is the tx for UTIs in patient with hx of HIV/AIDS?

FQ

What causes scrotal edema in young boys?

Idiopathic scrotal edema

What causes scrotal edema in older men?

CHF

What pts are most at risk for Fournier gangrene?

> 50 yo, DM, heavy alcohol use, immunocompromised

What is the tx for Fournier gangrene?

immediate and aggressive removal of necrotic tissue is crucial (progresses rapidly)

IV abx -Clinda, cipro, zosyn

What is balanoposthitis?

inflammation of the glans and foreskin

*recurrent can be sole presenting sign of DM

What is the MCC of balanoposthitis?

Candida

(2nd: Gardnerella)

What is the tx for Balanoposthitis?

cleaning w/ soap, antifungal creams, oral azole, abx if bacterial, possible circumcision

What is phimosis?

inability to retract the foreskin proximally and posterior to the glans penis

What is the tx for phimosis?

Topical steroid x4-6 weeks

Circumcision (definitive tx)

What is paraphimomsis?

inability to reduce the proximal edematous foreskin distally over the glans penis

*EMERGENCY -can lead to arterial compromise

What is the tx for paraphimosis?

Superficial dorsal incision of the band → allows foreskin reduction

(done in ER)

What is an acute tear or rupture of the corpus cavernosa tunica albuginea?

Penis fracture

How does a penis fracture present?

blunt trauma to erect penis or trauma during sexual activity, a "snapping sound" occurs followed by immediate loss of erection

What is the tx for a penile fracture?

prompt surgical repair to prevent complication

What is Peyronie's disease?

progressive penile deformity, typically curvature with erections

exam will reveal a thickened plaque, typically on the dorsum of shaft

What is Peyronie's disease associated with?

Dupuytren's contractures of the hand

What is priapism?

persistent, painful, pathologic erection

What causes priapism in children?

Sickle cell disease

What is the tx for priapism?

analgesia, corporal aspiration, phenylephrine injection

How does penile carcinoma present?

nontender ulcer or warty growth beneath the foreskin in the area of the coronal sulcus or glans penis

How does testicular torsion present?

testicle is firm, tender, elevated, epididymis is displaced, cremasteric reflex is absent

How do you perform a manual detorsion of the testicle?

*most torsions twist inward, toward midline

Twist outward & laterally

What is Prehn's sign?

relief of epididymis pain when recumbent with scrotal elevation

What are common causes of epididymitis?

< 35 yo = STDs or urethral strictures

> 40 = E. coli or Klebsiella

What is orchitis?

usually unilateral inflammation of the testicle

What is a viral cause of orchitis?

Mumps

How does testicular malignancy present?

asymptomatic testicular mass, firmness, or induration = hallmark

What is acute prostatitis?

bacterial inflammation of the prostate gland

*MCC = E. coli

How does acute prostatitis present?

perineal tenderness, rectal sphincter spasm, prostatic tenderness

What is the tx for acute prostatitis?

Ciprofloxacin

(alt = Bactrim)

What is the MCC of urethritis?

Chlamydia and gonorrhea

What is the tx for urethritis?

Ceftriaxone + Azithromycin or Doxycycline

What are the majority of renal & ureteral stones composed of?

Calcium

What's the main reason why someone would not be able to pass a stone?

Size

How do kidney stones present?

pain originates in flank, radiates antero-inferiorly around abd into the testicle or labium majorum, intense pain with N/V, diaphoresis, pts are anxious, pacing, and reluctant to lie still

What is the preferred imaging for evaluation of kidney stone?

CT

*US for pregnant women

What is the tx of kidney stones in ED?

mainstay = pain control; 0.9% NS, IV Zofran, IV Toradol

small stone = d/c analgesics, antiemetics, Flomax w/ strainer

Which stones are likely to pass?

< 4mm

> 8mm unlikely

What does painless hematuria indicate?

neoplastic, hyperplasticity, vascular cause

What does gross hematuria indicate?

Lower-tract cause

What does microscopic hematuria indicate?

Kidney disease

What is a frequent cause of hematuria?

Strenuous exercise

What is the tx for intravesical clot formation & bladder outlet obstruction secondary to gross hematuria?

Triple-lumen urinary drainage catheter & bladder irrigation

What are common causes of hematospermia in patients < 40 y/o?

infections, inflammatory conditions (orchitis, epididymitis)

What are common causes of hematospermia in patients > 40 y/o?

prostate tumors & BPH